Implementation of a delirium assessment tool in the ICU can influence haloperidol use

Attitudes, knowledge and practices concerning delirium among paediatric intensive care unit nurses: a multisite cross-sectional study in Sichuan, China

BACKGROUND

Delirium is an acute mental state associated with poor outcomes. The incidence of delirium is high, especially in the paediatric intensive care unit (PICU). It is important for staff, particularly nurses, to understand delirium and implement interventions to prevent it. We performed a survey with the aim of evaluating and analysing the factors influencing the knowledge, attitudes and behaviour of PICU nurses towards delirium.

METHODS

This cross-sectional descriptive study included 215 PICU nurses in 6 PICUs from five teaching hospitals in Sichuan Province, China. An online survey about the knowledge, attitudes and practices related to delirium care was conducted among PICU nurses used a self-made and validated questionnaire. The data were analysed using descriptive statistics; differences between groups were compared using t tests, ANOVA and rank-sum tests. Variables with a significance level of 0.05 in the univariate analysis were entered into the multivariable regression analysis to identify predictors.

RESULTS

Only 14.4% of the nurses had a good understanding of delirium, and 40.9% had received relevant training. The mean knowledge score was 9.01 ± 3.86, and the overall passing rate of knowledge was 49.8%. The mean attitude and behaviour scores were 40.95 ± 5.62 and 40.33 ± 8.01, respectively. Among the hospitals, different delirium assessments for children and specific training were performed, explaining approximately 10% of the variability in knowledge scores (F = 6.152), approximately 10% of the variability in attitude/belief scores (F = 5.908), and approximately 17% of the variability in practice scores (F = 10.767).

CONCLUSIONS

PICU nurses have poor knowledge of delirium, particularly regarding its clinical manifestations, influencing factors and medications used, and they have adequate attitudes and confidence and good behaviour regarding delirium in children. To better prevent delirium, we suggest that PICU departments routinely assess delirium and conduct delirium training for nurses.

TRIAL REGISTRATION

Not applicable.

Performance and validation of two ICU delirium assessment and severity tools; a prospective observational study

BACKGROUND

The clinical statistical performance of the Confusion Assessment Method Intensive Care Unit (CAM-ICU, including CAM-ICU-7) and Intensive Care Delirium Screening Checklist (ICDSC) have rarely been studied. Additionally, delirium severity is often not measured due to a lack of validation of delirium assessment tools.

OBJECTIVE

The aim was to determine the statistical performance of both delirium assessment tools in daily practice, and the correlation with the gold standard Delirium Rating Scale (DRS)-R98, for delirium severity.

RESEARCH METHOD

CAM-ICU-7 and ICDSC, performed by nurses were compared with the DRS-R98 assessed by delirium experts, twice weekly. Within a time-window of one hour all assessments were independently performed.

DESIGN

A prospective observational study performed between October and December 2020.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive value of both tools was determined. The correlation between DRS-R98 and CAM-ICU-7 and ICDSC was used for validation of delirium severity.

RESULTS

In total, 104 CAM-ICU-7 and 105 ICDSC assessments in 86 patients were compared with the DRS-R98. For the CAM-ICU-7 and ICDSC, respectively, the sensitivity was 90% and 95%, the specificity was 92.4% and 92.3%. The positive predictive value was 0.76 and 0.80, and negative predictive value was 0.77 and 0.97. Correlation of the CAM-ICU-7 score and ICDSC score with the DRS-R98 score was 0.74 (95% CI 0.64-0.81) and 0.70 (95%CI 0.59-0.79; both p < 0.001), respectively.

CONCLUSION

Both CAM-ICU-7 and ICDSC demonstrated good statistical performance and correlated well with the delirium severity tool DRS-R98.

IMPLICATIONS FOR CLINICAL PRACTICE

Nurses can either use the CAM-ICU(-7) or the ICDSC in their practice, both are accurate in delirium diagnosis. Total CAM-ICU-7 and ICDSC score reflects delirium severity well; the higher the score, the more severe the delirium. This enables nurses to gauge the impact of their interventions and enhance the well-being of patients experiencing delirium by minimizing distressing occurrences.

Effect of the clinical decision assessment system on clinical outcomes of delirium in hospitalized older adults: study protocol for a pair-matched, parallel, cluster randomized controlled superiority trial

BACKGROUND

Prompt recognition of delirium is the first key step in its proper management. A previous study has demonstrated that nurses' delirium screening using the usual paper version assessment tool has no effect on clinical outcomes. Clinical decision assessment systems have been demonstrated to improve patients' adherence and clinical outcomes. Therefore, We developed a clinical decision assessment system (3D-DST) based on the usual paper version (3-min diagnostic interview for CAM-defined delirium), which was developed for assessing delirium in older adults with high usability and accuracy. However, no high quality evidence exists on the effectiveness of a 3D-DST in improving outcomes of older adults compared to the usual paper version.

METHODS

A pair-matched, open-label, parallel, cluster randomized controlled superiority trial following the SPIRIT checklist. Older patients aged 65 years or older admitted to four medical wards of a geriatric hospital will be invited to participate in the study. Prior to the study, delirium prevention and treatment interventions will be delivered to nurses in both the intervention and control groups. The nurses in the intervention group will perform routine delirium assessments on the included older patients with 3D-DST, while the nurses in the control group will perform daily delirium assessments with the usual paper version. Enrolled patients will be assessed twice daily for delirium by a nurse researcher using 3D-DST. The primary outcome is delirium duration. The secondary outcomes are delirium severity, incidence of delirium, length of stay, in-hospital mortality, adherence to delirium assessment, prevention, and treatment of medical staff.

DISCUSSION

This study will incorporate the 3D-DST into clinical practice for delirium assessment. If our study will demonstrate that 3D-DST will improve adherence with delirium assessment and clinical outcomes in older patients, it will provide important evidence for the management of delirium in the future.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, Identifier: ChiCTR1900028402. https://www.chictr.org.cn/showproj.aspx?proj=47127 .

PROTOCOL VERSION

1, 29/7/22.

Recognizing and Reducing Delirium in the Intensive Care Unit

This article discusses a quality improvement study conducted on intensive care unit (ICU) staff nurses that assessed their ability to utilize the CAM-ICU tool for delirium detection properly. Staff members' expertise in identifying and managing delirious patients directly correlates with reducing the long-term sequelae associated with ICU delirium. The cohort of ICU nurses participating in this research study took a questionnaire on 4 separate occasions. The survey ascertained quantitative and qualitative data, reflecting personal knowledge about the CAM-ICU tool and delirium. After each round of assessment, group and one-on-one educational sessions were provided by the researchers. The study culminated with providing each staff member a delirium reference card (badge buddy) containing relevant and easily accessible clinical information that supported the ICU staff nurses in correctly implementing the CAM-ICU tool.

The effect of delirium information training given to intensive care nurses on patient care: quasi-experimental study

Background

Training programs aiming to improve delirium diagnosis and management skills increase nurses' care efficiency and improve patients' health outcomes. This study was conducted to examine the effect of delirium information training on patient care by intensive care nurses.

Methods

In the research, one group pretest-posttest quasi-experimental design was used. The study sample consisted of 30 nurses working in four intensive care units of a university hospital between November 05, 2018, and February 15, 2019. The Personal Information Form, the Checklist for the Care of the Patient in Delirium, and the Confusion Assessment Scale for the Intensive Care Unit were used to collect the data. Intensive care nurses were provided with information training supported by a training booklet in two sessions of 40 min each.

Results

In the study, according to the Checklist for the Care of the Patient in Delirium, while the pre-test point average of the nurses was 6.17 ± 2.29, the post-test point average had increased to 11.17 ± 1.51 (p < 0.001). After the training, it was determined that there was a significant increase in the percentage of nurses who stated that they evaluated and detected whether their patients had pain, hallucinations, and delusions (p < 0.001). As a result, it has been determined that providing delirium information training to intensive care nurses positively affects the care of patients with delirium. In addition, it has been determined that with the Confusion Assessment Scale for Intensive Care Unit, nurses can provide the care they need to patients at risk in terms of delirium by identifying delirium.

Pediatric Anesthesia Emergence Delirium Scale: A diagnostic meta-analysis

BACKGROUND

Emergence delirium (EmD) is a troublesome motoric, emotional, and cognitive disturbance associated with morbidity. It is often misdiagnosed despite being present in a substantial proportion of children and adolescents during emergence from anesthesia.

AIM

To evaluate the summary diagnostic accuracy of Pediatric Anesthesia Emergence Delirium Scale (PAEDS) for EmD among children and adolescents.

METHODS

Two researchers electronically and hand searched the published literature from May 2004 to February 2021 that evaluated the diagnostic accuracy of PAEDS for EmD among children and adolescents, using appropriate terms. Two independent researchers extracted the diagnostic parameters and appraised the study quality with QUADAS-2. Overall, the diagnostic accuracy of the measures was calculated with the summary receiver operating characteristic curve (SROC), the summary sensitivity and specificity, and diagnostic odds ratio (DOR) for EmD. Various diagnostic cut-off points were evaluated for their diagnostic accuracy. Heterogeneity was analyzed by meta-regression.

RESULTS

Nine diagnostic accuracy studies of EmD that conformed to our selection criteria and PRISMA guidelines were included in the final analysis. There was no publication bias. The area under the SROC was 0.97 (95% confidence interval [CI]: 95%-98%). Summary sensitivity and specificity were 0.91 (95%CI: 0.81-0.96; I² = 92.93%) and 0.94 (95%CI: 0.89-0.97; I² = 87.44%), respectively. The summary DOR was 148.33 (95%CI: 48.32-455.32). The effect size for the subgroup analysis of PAEDS cut-off scores of < 10, ≥ 10, and ≥ 12 was 3.73, 2.19, and 2.93, respectively; they were not statistically significantly different. The setting of the study and reference standard were statistically significantly related to the sensitivity of PAEDS but not specificity.

CONCLUSION

The PAEDS is an accurate diagnostic measure for the diagnosis of EmD among children and adolescents. Further studies should document its clinical utility.

Barriers and facilitators to nursing delirium screening in older emergency patients: a qualitative study using the theoretical domains framework

BACKGROUND

delirium is common in older emergency department (ED) patients, but vastly under-recognised, in part due to lack of standardised screening processes. Understanding local context and barriers to delirium screening are integral for successful implementation of a delirium screening protocol.

OBJECTIVES

we sought to identify barriers and facilitators to delirium screening by nurses in older ED patients.

METHODS

we conducted 15 semi-structured, face-to-face interviews based on the Theoretical Domains Framework with bedside nurses, nurse educators and managers at two academic EDs in 2017. Two research assistants independently coded transcripts. Relevant domains and themes were identified.

RESULTS

a total of 717 utterances were coded into 14 domains. Three dominant themes emerged: (i) lack of clinical prioritisation because of competing demands, lack of time and heavy workload; (ii) discordance between perceived capabilities and knowledge and (iii) hospital culture.

CONCLUSION

this qualitative study explored nursing barriers and facilitators to delirium screening in older ED patients. We found that delirium was recognised as an important clinical problem; however, it was not clinically prioritised; there was a false self-perception of knowledge and ability to recognise delirium and hospital culture was a strong influencer of behaviour. Successful adoption of a delirium screening protocol will only be realised if these issues are addressed.

Development of a delirium predictive model for adult trauma patients in an emergency and critical care center: a retrospective study

Background

Delirium has been shown to prolong the length of intensive care unit stay, hospitalization, and duration of ventilatory control, in addition to increasing the use of sedatives and increasing the medical costs. Although there have been a number of reports referring to risk factors for the development of delirium, no model has been developed to predict delirium in trauma patients at the time of admission. This study aimed to create a scoring system that predicts delirium in trauma patients.

Methods

In this single-center, retrospective, observational study, trauma patients aged 18 years and older requiring hospitalization more than 48 hours were included and divided into the development and validation cohorts. Univariate analysis was performed in the development cohort to identify factors significantly associated with prediction of delirium. The final scoring system for predicting delirium was developed using multivariate analysis and internal validation was performed.

Results

Of the 308 patients in the development cohort, 91 developed delirium. Clinical Frailty Score, fibrin/fibrinogen degradation products, low body mass index, lactate level, and Glasgow Coma Scale score were independently associated with the development of delirium. We developed a scoring system using these factors and calculated the delirium predictive score, which had an area under the curve of 0.85. In the validation cohort, 46 of 206 patients developed delirium. The area under the curve for the validation cohort was 0.86, and the calibration plot analysis revealed the scoring system was well calibrated in the validation cohort.

Discussion

This scoring system for predicting delirium in trauma patients consists of only five risk factors. Delirium prediction at the time of admission may be useful in clinical practice.

Level of evidence

Prognostic and epidemiological, level III.

Advantages of score-based delirium detection compared to a clinical delirium assessment-a retrospective, monocentric cohort study

Purpose

Delirium is an underdiagnosed complication on intensive care units (ICU). We hypothesized that a score-based delirium detection using the Nudesc score identifies more patients compared to a traditional diagnosis of delirium by ICU physicians.

Methods

In this retrospective study, all patients treated on a general medical ICU with 30 beds in a university hospital in 2019 were analyzed. Primary outcome was a documented physician diagnosis of delirium, or a delirium score ≥2 using the Nudesc.

Results

In 205/943 included patients (21.7%), delirium was diagnosed by ICU physicians compared to 438/943 (46.4%; ratio 2.1) by Nudesc≥2. Both assessments were independent predictors of ICU stay (p<0.01). The physician diagnosis however was no independent predictor of mortality (OR 0.98 (0.57–1.72); p = 0.989), in contrast to the score-based diagnosis (OR 2.31 (1.30–4.10); p = 0.004). Subgroup analysis showed that physicians underdiagnosed delirium in case of hypoactive delirium and delirium in patients with female gender and in patients with an age below 60 years.

Conclusion

Delirium in patients with hypoactive delirium, female patients and those below 60 years was underdiagnosed by physicians. The score-based delirium diagnosis detected delirium more frequently and correlated with ICU mortality and stay.

Factors Influencing CAM-ICU Documentation and Inappropriate "Unable to Assess" Responses

BACKGROUND

Detecting delirium with standardized assessment tools such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is important, but such detection is frequently hampered by poor documentation and inappropriate "unable to assess" responses (in noncomatose patients).

OBJECTIVE

To identify patient, clinical, and workplace factors that may impede or facilitate appropriate delirium assessment through use of the CAM-ICU, specifically documentation and inappropriate "unable to assess" responses.

METHODS

An electronic health record-based data set was used to quantify CAM-ICU documentation and inappropriate "unable to assess" responses during 24 months. Associated patient (eg, age), clinical (eg, diagnosis), and workplace (eg, geographic location within the ICU, shift) factors were evaluated with multivariable regression.

RESULTS

Of 28 586 CAM-ICU documentation opportunities, 66% were documented; 16% of documentations in alert or lightly sedated patients had inappropriate "unable to assess" responses. Night shift was associated with lower CAM-ICU documentation rates (P = .001), whereas physical restraints and location on side B (rather than side A) of the ICU were associated with higher documentation rates (P < .05 for both). Age older than 80 years, non-White race, intubation, and physical restraints were associated with more inappropriate "unable to assess" responses (all P < .05), as was infusion of propofol, midazolam, dexmedetomidine, or fentanyl (all P < .05).

CONCLUSION

Data from electronic health records can identify patient, clinical, and workplace factors associated with CAM-ICU documentation and inappropriate "unable to assess" responses, which can help target quality improvement efforts related to delirium assessment.

Factors associated with a persistent delirium in the intensive care unit: A retrospective cohort study

PURPOSE

To explore differences between ICU patients with persistent delirium (PD), non-persistent delirium (NPD) and no delirium (ND), and to determine factors associated with PD.

MATERIALS AND METHODS

Retrospective cohort study including all ICU adults admitted for ≥12 h (January 2015-February 2020), assessable for delirium and followed during their entire hospitalization. PD was defined as ≥14 days of delirium. Factors associated with PD were determined using multivariable logistic regression analysis.

RESULTS

Out of 10,295 patients, 3138 (30.5%) had delirium, and 284 (2.8%) had PD. As compared to NPD (n = 2854, 27.7%) and ND (n = 7157, 69.5%), PD patients were older, sicker, more physically restrained, longer comatose and mechanically ventilated, had a longer ICU and hospital stay, more ICU readmissions and a higher mortality rate. Factors associated with PD were age (adjusted odds ratio [aOR] 1.03; 95% confidence interval [CI] 1.02-1.04); emergency surgical (aOR 1.84; 95%CI 1.26-2.68) and medical (aOR 1.57; 95%CI 1.12-2.21) referral, mean Sequential Organ Failure Assessment (SOFA) score before delirium onset (aOR 1.18; 95%CI 1.13-1.24) and use of physical restraints (aOR 5.02; 95%CI 3.09-8.15).

CONCLUSIONS

Patients with persistent delirium differ in several characteristics and had worse short-term outcomes. Physical restraints were the most strongly associated with PD.

Delirium in Intensive Care

Purpose of Review

Delirium in the intensive care unit (ICU) has become increasingly acknowledged as a significant problem for critically ill patients affecting both the actual course of illness as well as outcomes. In this review, we focus on the current evidence and the gaps in knowledge.

Recent Findings

This review highlights several areas in which the evidence is weak and further research is needed in both pharmacological and non-pharmacological treatment. A better understanding of subtypes and their different response to therapy is needed and further studies in aetiology are warranted. Larger studies are needed to explore risk factors for developing delirium and for examining long-term consequences. Finally, a stronger focus on experienced delirium and considering the perspectives of both patients and their families is encouraged.

Summary

With the growing number of studies and a better framework for research leading to stronger evidence, the outcomes for patients suffering from delirium will most definitely improve in the years to come.

Cluster nursing can reduce postoperative delirium and improve the negative emotions and quality of life of elderly ICU patients

OBJECTIVE

To explore the application effect of cluster nursing in post-surgery elderly patients in intensive care units (ICU).

METHODS

From March 2019 to August 2020, a total of 167 elderly patients admitted to the ICU in Changzhou No. 2 People's Hospital, the Affiliated Hospital of Nanjing Medical University were recruited as the study cohort. They were divided into a test group (n=85) and a control group (n=82). The patients in the control group underwent routine nursing, and the patients in the test group underwent cluster nursing in addition to the nursing the control group underwent. The two groups' incidences of delirium, their quality of life, and their mental health were compared.

RESULTS

The total incidences of delirium in the test group were significantly lower than they were in the control group, and the delirium outcome rate was significantly higher than it was in the control group. A comparison of the Acute Physiology and Chronic Health Evaluation (APACHE ll) and Symptom Checklist-90 (SCL-90) scores before and after the nursing showed that the test group had notably lower scores than the control group. In addition, the nursing satisfaction rate in the test group was 88.24%, which was significantly higher than the rate in the control group (73.17%). The hospitalization expenses of the test group were lower, with a notably improved quality of life.

CONCLUSION

Cluster nursing can reduce the incidence of delirium and improve the quality of life and mental health of post-surgery elderly ICU patients.

Prevention and Management of Delirium in the Intensive Care Unit

Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.

Screening and detection of delirium in an adult critical care setting: a best practice implementation project

AIM

To assess compliance with evidence-based practice regarding screening and detection of delirium in adult patients at the ICU from a university hospital.

METHODS

The compliance rates were evaluated using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. This strategy was designed in three phases: (1) establishing a team and conducting a baseline audit based on criteria informed by the evidence; (2) reflecting on the results of the baseline audit and designing and implementing strategies to address noncompliance found in the baseline audit informed by the JBI Getting Research into Practice framework; and (3) conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice and identify future practice issues to be addressed in subsequent audits. The implementation protocol was designed based on the primary barriers and facilitators identified in the baseline audit, allied to a training program and electronic medical records changes. Nursing documentation available in medical records from patients admitted in the ICU was used to assess the baseline and follow-up audit compliance rates.

RESULTS

None of the medical records evaluated before the implementation protocol showed compliance with the following audit criteria: a valid and reliable instrument is accessible in the ward environment (0%), the nursing care documentation supports that the Confusion Assessment Method for the Intensive Care Unit instrument is being used (0%) and population assessed for delirium includes all adults over the age of 65, cognitive impairment, dementia, or both, current hip fracture and severe illness (0%). After the evidence-based practice implementation, the follow-up audit revealed up to 100% compliance rates with those criteria, showing that all patients under risk were screened and assessed for delirium. The only exception was the Confusion Assessment Method for the Intensive Care Unit use, whose compliance was observed in 80.95% of the medical records.

CONCLUSION

These findings support that baseline and follow-up audits allied to a delirium training program, and changes in the electronic nursing records increase the compliance rates related to the evidence-based practice for screening patients under risk and assessing delirium.

Bispectral Index Monitoring With Density Spectral Array for Delirium Detection

BACKGROUND

Delirium in hospitalized patients often goes undetected. Cerebral state monitors, which measure limited-channel electroencephalography, have shown potential for improving delirium detection.

OBJECTIVE

The aim of this study was to compare an FDA-approved cerebral state monitor, bispectral index monitoring with density spectral array (DSA), for delirium identification with clinical screening methods.

METHODS

Hospitalized patients receiving psychiatric consultation were assessed for delirium using the 3-minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) and underwent bispectral index monitor + DSA monitoring. Visual inspection of frequency band power of the DSA was performed by 2 trained independent raters. Average hue values were calculated for each frequency band using image analysis software as the device did not allow for extraction of raw electroencephalography data. Delirious versus nondelirious group averages, sensitivity, specificity, and area under the curve were calculated for significant DSA variables and the 3D-CAM.

RESULTS

In an initial cohort of 43 patients, visual ratings of the DSA were not associated with delirium (P > 0.1). In a larger cohort of 123 subjects, multiple band hue ratios were associated with delirium, although none survived correction for multiple comparisons. In a subgroup of 74 non-neurological patients, low theta/low delta ratio was significantly associated with delirium (P = 0.001) (sensitivity/specificity/area under the curve: 83%/70%/0.757; 3D-CAM: 67%/77%/0.717; paired-sample area under the curve difference: -0.040, P = 0.68). In 21 patients with dementia, low theta power demonstrated significantly greater sensitivity/specificity/area under the curve of 83%/78%/0.824, whereas 3D-CAM achieved 50%/78%/0.639 (P = 0.04).

CONCLUSION

Bispectral index monitor + DSA was similar to 3D-CAM for detecting delirium in hospitalized patients with and without neurological disorders, and was significantly more accurate in patients with dementia. More studies are needed to validate the use of cerebral state monitors for quantitative delirium detection.

Implementation strategies used to implement nursing guidelines in daily practice: A systematic review

OBJECTIVES

Research specifically addressing implementation strategies regarding nursing guidelines is limited. The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields, as well as the effects of these strategies on patient-related nursing outcomes and guideline adherence. Ideally, the findings would help guideline developers, healthcare professionals and organizations to implement nursing guidelines in practice.

DESIGN

Systematic review. PROSPERO registration number: CRD42018104615.

DATA SOURCES

We searched the Embase, Medline, PsycINFO, Web of Science, Cochrane, CINAHL and Google Scholar databases until August 2019 as well as the reference lists of relevant articles.

REVIEW METHODS

Studies were included that described quantitative data on the effect of implementation strategies and implementation outcomes of any type of a nursing guideline in any setting. No language or date of publication restriction was used. The Cochrane Effective Practice and Organisation of Care taxonomy was used to categorize the implementation strategies. Studies were classified as effective if a significant change in either patient-related nursing outcomes or guideline adherence was described. Strength of the evidence was evaluated using the 'Cochrane risk of bias tool' for controlled studies, and the 'Newcastle-Ottawa Quality Assessment form' for cohort studies.

RESULTS

A total of 54 articles regarding 53 different guideline implementation studies were included. Fifteen were (cluster) Randomized Controlled Trials or controlled before-after studies and 38 studies had a before-after design. The topics of the implemented guidelines were diverse, mostly concerning skin care (n = 9) and infection prevention (n = 7). Studies were predominantly performed in hospitals (n = 34) and nursing homes (n = 11). Thirty studies showed a positive significant effect in either patient-related nursing outcomes or guideline adherence (68%, n = 36). The median number of implementation strategies used was 6 (IQR 4-8) per study. Educational strategies were used in nearly all studies (98.1%, n = 52), followed by deployment of local opinion leaders (54.7%, n = 29) and audit and feedback (41.5%, n = 22). Twenty-three (43.4%) studies performed a barrier assessment, nineteen used tailored strategies.

CONCLUSIONS

A wide variety of implementation strategies are used to implement nursing guidelines. Not one single strategy, or combination of strategies, can be linked directly to successful implementation of nursing guidelines. Overall, thirty-six studies (68%) reported a positive significant effect of the implementation of guidelines on patient-related nursing outcomes or guideline adherence. Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategies to increase reproducibility and understanding of outcomes.

Delirium risk prediction models for intensive care unit patients: A systematic review

OBJECTIVE

To systematically review the delirium risk prediction models for intensive care unit (ICU) patients.

METHODS

A systematic review was conducted. The Cochrane Library, PubMed, Ovid and Web of Science were searched to collect studies on delirium risk prediction models for ICU patients from database establishment to 31 March 2019. Two reviewers independently screened the literature according to the pre-determined inclusion and exclusion criteria, extracted the data and evaluated the risk of bias of the included studies using the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies) checklist. A descriptive analysis was used to describe and summarise the data.

RESULTS

A total of six models were included. All studies reported the area under the receiver operating characteristic curve (AUROC) of the prediction models in the derivation and (or) validation datasets as over 0.7 (from 0.75 to 0.9). Five models reported calibration metrics. Decreased cognitive reserve and the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score were the most commonly reported predisposing and precipitating factors, respectively, of ICU delirium among all models. The small sample size, lack of external validation and the absence of or unreported blinding method increased the risk of bias.

CONCLUSION

According to the discrimination and calibration statistics reported in the original studies, six prediction models may have moderate power in predicting ICU delirium. However, this finding should be interpreted with caution due to the risk of bias in the included studies. More clinical studies should be carried out to validate whether these tools have satisfactory predictive performance in delirium risk prediction for ICU patients.

Preoperative cardiac function parameters as valuable predictors for nurses to recognise delirium after cardiac surgery: A prospective cohort study

BACKGROUND

Delirium is a common postoperative complication after cardiac surgery. The relationship between delirium and cardiac function has not been fully elucidated.

AIMS

The aim of this study was to identify the association between preoperative cardiac function and delirium among patients after cardiac surgery.

METHODS

We prospectively recruited 635 cardiac surgery patients with a planned cardiac intensive care unit admission. Postoperative delirium was diagnosed using the confusion assessment method for the intensive care unit. Preoperative cardiac function was assessed using N-terminal prohormone of brain natriuretic peptide (NT-proBNP), New York Heart Association functional classification and left ventricular ejection fraction.

RESULTS

Delirium developed in 73 patients (11.5%) during intensive care unit stay. NT-proBNP level (odds ratio (OR) 1.24, 95% confidence interval (CI) 1.01-1.52) and New York Heart Association functional classification (OR 2.34, 95% CI 1.27-4.31) were both independently associated with the occurrence of delirium after adjusting for various confounders. The OR of delirium increased with increasing NT-proBNP levels after the turning point of 7.8 (log-transformed pg/ml). The adjusted regression coefficients were 1.19 (95% CI 0.95-1.49, P=0.134) for NT-proBNP less than 7.8 (log-transformed pg/ml) and 2.78 (95% CI 1.09-7.12, P=0.033) for NT-proBNP greater than 7.8 (log-transformed pg/ml). No association was found between left ventricular ejection fraction and postoperative delirium.

CONCLUSION

Preoperative cardiac function parameters including NT-proBNP and New York Heart Association functional classification can predict the incidence of delirium following cardiac surgery. We suggest incorporating an early determination of preoperative cardiac function as a readily available risk assessment for delirium prior to cardiac surgery.

Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

OBJECTIVE

To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.

DESIGN

Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017.

METHODS

Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified.

RESULTS

The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation.

CONCLUSIONS

We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

Incidence and risk factors of PostopeRativE delirium in intensive care unit patients: A study protocol for the PREDICt study

AIM

The aims of this study are: (a) to determine the incidence of postoperative delirium (POD) among surgical intensive care unit (ICU) patients in China and identify risk factors, especially, which are modifiable and have value for developing a prediction model; (b) to develop and validate a prediction model of delirium to recognize high-risk patients in surgical ICUs; (c) to investigate the short- and long-term outcomes of delirious patients and identify the predictors of patient outcomes.

DESIGN

A single-centre prospective cohort study.

METHODS

Patients will be enrolled from three surgical ICUs in a tertiary teaching hospital. Delirium assessment and perioperative data will be collected throughout the hospitalization. Delirious patients will be followed up for 2 years. The study was approved by the ethics committee in May 2018 and was funded by the clinical research grant from Zhongshan hospital, Fudan University, Shanghai.

DISCUSSION

Developing POD can be a burden to patients both for the short- and long-term period. Due to the lack of effective treatments for POD, prevention remains the best strategy. This study will provide an effective tool for early screening of high-risk patients of POD and provide a better understanding of the aetiology and outcome of delirium.

IMPACT

In clinical practice, a prediction model will offer an effective tool for ICU nurses to assess high-risk patients, which can support them to implement preventive strategies at the early stages to targeted patients. The follow-up results will help us better understand the impact of delirium on patients' long-term outcome.

Overcoming Barriers to Delirium Screening in the Pediatric Intensive Care Unit

BACKGROUND

Delirium is associated with poor outcomes in adults but is less extensively studied in children.

OBJECTIVES

To describe a quality improvement initiative to implement delirium assessment in a pediatric intensive care unit and to identify barriers to delirium screening completion.

METHODS

A survey identified perceived barriers to delirium assessment. Failure modes and effects analysis characterized factors likely to impede assessment. A randomized case-control study evaluated factors affecting assessment by comparing patients always assessed with patients never assessed.

RESULTS

Delirium assessment was completed in 57% of opportunities over 1 year, with 2% positive screen results. Education improved screening completion by 20%. Barriers to assessment identified by survey (n = 25) included remembering to complete assessments, documentation outside workflow, and "busy patient." Factors with high risk prediction numbers were lack of time and paper charting. Patients always assessed had more severe illness (median Pediatric Index of Mortality 2 score, 0.90 vs 0.36; P < .001), more developmental disabilities (moderate to severe pediatric cerebral performance category score, 54% vs 32%; P = .007), and admission during lower pediatric intensive care unit census (median [interquartile range], 10 [9-12] vs 12 [10-13]; P < .001) than did those never assessed (each group, n = 80). Patients receiving mechanical ventilation were less likely to be assessed (41.0% vs 51.2%, P < .001).

CONCLUSIONS

Successful implementation of pediatric delirium screening may be associated with early use of quality improvement tools to identify assessment barriers, comprehensive education, monitoring system with feedback, multidisciplinary team involvement, and incorporation into nursing workflow models.

Evaluation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for the patients in the intensive care unit

Introduction

Delirium not only compromises patient care, but is also associated with poorer outcomes: increased duration of mechanical ventilation, higher mortality, and greater long-term cognitive dysfunction. The PRE-DELIRIC model is a tool used to calculate the risk of the development of delirium. The classification of the patients into groups by risk allows efficient initiation of preventive measures. The goal of this study was to validate the PRE-DELIRIC model using the CAM-ICU (The Confusion Assessment Method for the Intensive Care Unit) method for the diagnosis of delirium.

Materials and methods

Patients admitted to the University Hospital of Vilnius during February 2015 were enrolled. Every day, data were collected for APACHE-II and PRE-DELIRIC scores. Out of 167 patients, 38 (23%) were included and screened using the CAM-ICU method within 24 hours of admission to the ICU. We defined patients as having delirium when they had at least one positive CAM-ICU screening or haloperidol administration due to sedation. To validate the PRE-DELIRIC model, we calculated the area under receiver operating characteristic curve.

Results

The mean age of the patients was 69.2 ± 17.2 years, 19 (50%) were male, APACHE-II mean score 18.0 ± 7.4 points. Delirium was diagnosed in 22 (58%) of 38 patients. Data used for validation of the PRE-DELIRIC model resulted in an area under the curve of 0.713 (p < 0.05, 95% CI 0.539-0.887); sensitivity and specificity for the patients with 20% risk were, accordingly, 77.3% and 50%; 40% risk - 45.5% and 81.3%, 60% - 36.4%, and 87.5%.

Conclusions

The PRE-DELIRIC model predicted delirium in the patients within 24 hours of admission to the ICU. Preventive therapy could be efficiently targeted at high-risk patients if both of the methods are to be implemented.

Can education improve clinical practice concerning delirium in older hospitalised patients? Results of a pre-test post-test study on an educational intervention for nursing staff

BACKGROUND

Delirium is a common and serious complication of hospitalisation in older adults. It can lead to prolonged hospital stay, institutionalisation, and even death. However, it often remains unrecognised or is not managed adequately. The aim of this study was to evaluate the effects of an educational intervention for nursing staff on three aspects of clinical practice concerning delirium in older hospitalised patients: the frequency and correctness of screening for delirium using the 13-item Delirium Observation Screening score (DOS), and the frequency of geriatric consultations requested for older patients. The a priori expectations were that there would be an increase in all three of these outcomes.

METHODS

We designed an educational intervention and implemented this on two inpatient hospital units. Before providing the educational session, the nursing staff was asked to fill out two questionnaires about delirium in older hospitalised patients. The educational session was then tailored to each unit based on the results of these questionnaires. Additionally, posters and flyers with information on the screening and management of delirium were provided and participants were shown where to find additional information. Relevant data (outcomes, demographics and background patient data) were collected retrospectively from digital medical files. Data was retrospectively collected for four different time points: three pre-test and one post-test.

RESULTS

There was a significant increase in frequency of delirium screening (P = 0.001), and both units showed an increase in the correctness of the screening. No significant effect of the educational intervention was found for the proportion of patients who received a geriatric consultation (P = 0.083).

CONCLUSION

The educational intervention was fairly successful in making positive changes in clinical practice: after the educational session an improvement in the frequency and correctness of screening for delirium was observed. A trend, though not significant, towards an increase in the proportion of geriatric consultations for older hospitalised patients was also observed.

Perceptions, attitudes, and current practices regards delirium in China: A survey of 917 critical care nurses and physicians in China

The purpose of this study is to assess the knowledge, attitudes, and managements regarding delirium of intensive care nurses and physicans, and to assess the perceived barriers related to intensive care unit (ICU) delirium monitoring in China. A descriptive survey was distributed to 1156 critical care nurses and physicians from 74 tertiary and secondary hospitals across Shandong province, China. The overall response rate was 86.18% (n = 917). The majority of respondents (88%) believed that deirium was associated with prolonged mechanical ventilation, and 79.72% thought delirium was associated with prolonged length of hospitalization. Only 14.17% of respondents believed that delirium was common in the ICU setting. Only 25.62% of the respondents reported routine screening of ICU delirium, and only 15.81% utilized Confusion Assessment Method for Intensive Care Unit screening tools. "Lack of appropriate screening tools" and "time restraints" were the most common perceived barriers. 45.4% of the participants had never received any education on ICU delirium. In conclusion, most nurses and physicians consider ICU delirium to be a serious problem, but lack knowledge on delirium and monitor this condition poorly. The survey infers a disconnection between the perceived significance and current monitoring of ICU delirium. There is a critical unmet need for in-service education on ICU delirium for physicians and nurses in China.

Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review

BACKGROUND

Improved outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (ABCDE); however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and to provide a resource to guide clinicians in overcoming barriers to implementation.

METHODS

We searched MEDLINE via PubMed, CINAHL, and Scopus for original research articles from January 1, 2007, to August 31, 2016, that identified barriers to ABCDE implementation for adult patients in the ICU. Two reviewers independently reviewed studies, extracted barriers, and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed, and consensus was achieved.

RESULTS

Our electronic search yielded 1,908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified four classes of ABCDE barriers: (1) patient-related (ie, patient instability and safety concerns); (2) clinician-related (ie, lack of knowledge, staff safety concerns); (3) protocol-related (ie, unclear protocol criteria, cumbersome protocols to use); and, not previously identified in past reviews, (4) ICU contextual barriers (ie, interprofessional team care coordination).

CONCLUSIONS

We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.

Preventive strategies and potential therapeutic interventions for delirium in sepsis

Delirium is the most frequent and severe clinical presentation of brain dysfunction in critically ill septic patients with an incidence ranging from 9% to 71%. Delirium represents a significant burden for patients and relatives, as well as to the health care system, resulting in higher costs, long-term cognitive impairment and significant risk of death after 6 months. Current interventions for the prevention of delirium typically involve early recognition and amelioration of modifiable risk factors and treatment of underlying conditions that predisposes the individual to delirium. Several pharmacological interventions to prevent and treat delirium have been tested, although their effectiveness remains uncertain, especially in larger and more homogeneous subgroups of ICU patients, like in patients with sepsis. To date, there is inconsistent and conflicting data regarding the efficacy of any particular pharmacological agent, thus substantial attention has been paid to non-pharmacological interventions and preventive strategies should be applied to every patient admitted in the ICU. Future trials should be designed to evaluate the impact of these pharmacologic interventions on the prevention and treatment of delirium on clinically relevant outcomes such as length of stay, hospital mortality and long-term cognitive function. The role of specific medications like statins in delirium prevention is also yet to be evaluated.

Predictors of clinicians' underuse of daily sedation interruption and sedation scales

PURPOSE

The purpose of the study is to identify predictors of underuse of sedation scales and daily sedation interruption (DSI).

METHODS

We surveyed all physicians and seven nurses in every Belgian intensive care unit (ICU), addressing practices and perceptions on guideline recommendations. Underuse was defined for sedation scales as use less than 3× per day and for DSI as never using it. Classification trees and logistic regressions identified predictors of underuse.

RESULTS

Underuse of sedation scales and DSI was found for 16.6% and 32.5% of clinicians, respectively. Strongest predictors of underuse of sedation scales were agreeing that using them daily takes much time and being a physician (rather than a nurse). Further predictors were confidence in their ability to measure sedation levels without using scales, for physicians, and nurse/ICU bed ratios less than 1.98, for nurses. The strongest predictor of underuse of DSI among physicians was the perception that DSI impairs patients' comfort. Among nurses, lack of familiarity with DSI, region, and agreeing DSI should only be performed upon medical orders best predicted underuse.

CONCLUSIONS

Workload considerations hamper utilization of sedation scales. Poor familiarity, for nurses, and negative perception of impact on patients' comfort, for physicians, both reduce DSI utilization. Targeting these obstacles is essential while designing quality improvement strategies to minimize sedative use.

Attitudes, knowledge and practices concerning delirium: a survey among intensive care unit professionals

BACKGROUND

Delirium is a common form of vital organ dysfunction in intensive care unit (ICU) patients and is associated with poor outcomes. Adherence to guideline recommendations pertaining to delirium is still suboptimal.

AIMS

We performed a survey aimed at identifying barriers for implementation that should be addressed in a tailored implementation intervention targeted at improved ICU delirium guideline adherence.

DESIGN

The survey was conducted among ICU professionals.

METHODS

An online survey was conducted among 360 ICU health care professionals (nurses, physicians and delirium consultants) from six ICUs in the southwest of the Netherlands as part of a multicentre prospective implementation project [response rate: 64% of 565 invited; 283 (79%) were nurses].

RESULTS

Although the majority (83%) of respondents considered delirium a common and major problem in the ICU, we identified several barriers for implementation of a delirium guideline. The most important barriers were knowledge deficit, low delirium screening rate, lack of trust in the reliability of delirium screening tools, belief that delirium is not preventable, low familiarity with delirium guidelines, low satisfaction with physician-described delirium management, poor collaboration between nurses and physicians, reluctance to change delirium care practices, lack of time, disbelief that patients would receive optimal care when adhering to the guideline and the perception that the delirium guideline is cumbersome or inconvenient in daily practice.

CONCLUSION

Although ICU professionals consider delirium a serious problem, several important barriers to adhere to guidelines on delirium management are still present today.

RELEVANCE TO CLINICAL PRACTICE

Identification of implementation barriers for adherence to guidelines pertaining to delirium is feasible with a survey. Results of this study may help to design-targeted implementation strategies for ICU delirium management.

A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes

INTRODUCTION

Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians' ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes.

METHOD

We searched PubMed, Embase, PsychINFO, Cochrane and CINAHL (January 2000 and April 2014) for studies on implementation strategies that included delirium-oriented interventions in adult ICU patients. Studies were suitable for inclusion if implementation strategies' efficacy, in terms of a clinical outcome, or process outcome was described.

RESULTS

We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as "audit and feedback" and "tailored interventions" may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioral change, was also associated with reduced mortality.

CONCLUSION

Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes.

Improvement of care for ICU patients with delirium by early screening and treatment: study protocol of iDECePTIvE study

BACKGROUND

Delirium in critically ill patients has a strong adverse impact on prognosis. In spite of its recognized importance, however, delirium screening and treatment procedures are often not in accordance with current guidelines. This implementation study is designed to assess barriers and facilitators for guideline adherence and next to develop a multifaceted tailored implementation strategy. Effects of this strategy on guideline adherence as well as important clinical outcomes will be described.

METHODS

Current practices and guideline deviations will be assessed in a prospective baseline measurement. Barriers and facilitators will be identified from a survey among intensive care health care professionals (intensivists and nurses) and focus group interviews with selected health care professionals (n=60). Findings will serve as a foundation for a tailored guideline implementation strategy. Adherence to the guideline and effects of the implementation strategies on relevant clinical outcomes will be piloted in a before-after study in six intensive care units (ICUs) in the southwest Netherlands. The primary outcomes are adherence to screening and treatment in line with the Dutch ICU delirium guideline. Secondary outcomes are process measures (e.g. attendance to training and knowledge) and clinical outcomes (e.g. incidence of delirium, hospital-mortality changes, and length of stay). Primary and secondary outcome data will be collected at four time points including at least 924 patients. Furthermore, a process evaluation will be done, including an economical evaluation.

DISCUSSION

Little is known on effective implementation of delirium management in the critically ill. The proposed multifaceted implementation strategy is expected to improve process measures such as screening adherence in line with the guideline and may improve clinical outcomes, such as mortality and length of stay. This ICU Delirium in Clinical Practice Implementation Evaluation study (iDECePTIvE-study) will generate important knowledge for ICU health care providers on how to improve their clinical practice to establish optimum care for delirious patients.

TRIALS REGISTRATION

Clinical Trials NCT01952899.

Validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU)

Purpose

The purpose of this study was to determine the validity and reliability of the Thai version of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), when compared to the diagnoses made by delirium experts.

Patients and methods

This was a cross-sectional study conducted in both surgical intensive care and subintensive care units in Thailand between February–June 2011. Seventy patients aged 60 years or older who had been admitted to the units were enrolled into the study within the first 48 hours of admission. Each patient was randomly assessed as to whether they had delirium by a nurse using the Thai version of the CAM-ICU algorithm (Thai CAM-ICU) or by a delirium expert using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.

Results

The prevalence of delirium was found to be 18.6% (n=13) by the delirium experts. The sensitivity of the Thai CAM-ICU’s algorithms was found to be 92.3% (95% confidence interval [CI] =64.0%−99.8%), while the specificity was 94.7% (95% CI =85.4%−98.9%). The instrument displayed good interrater reliability (Cohen’s κ =0.81; 95% CI =0.64−0.99). The time taken to complete the Thai CAM-ICU was 1 minute (interquatile range, 1−2 minutes).

Conclusion

The Thai CAM-ICU demonstrated good validity, reliability, and ease of use when diagnosing delirium in a surgical intensive care unit setting. The use of this diagnostic tool should be encouraged for daily, routine use, so as to promote the early detection of delirium and its rapid treatment.

Improved nurse-parent communication in neonatal intensive care unit: evaluation and adjustment of an implementation strategy

AIMS AND OBJECTIVES

To evaluate and adjust systematic implementation of guided family-centred care in a neonatal intensive care unit.

BACKGROUND

Family-centred care is valued in neonatal intensive care units internationally, but innovative strategies are needed to realise the principles. Guided family-centred care was developed to facilitate person-centred communication by bridging the gap between theory and practice in family-centred care. Main mechanisms of guided family-centred care are structured dialogue, reflection and person-centred communication.

DESIGN

Qualitative and quantitative data were used to monitor participatory implementation of a systematic approach to training and certification of nurses delivering guided family-centred care.

METHODS

Systematic implementation of guided family-centred care included workshops, supervised delivery and certification. Evaluation and adjustment of nurse adherence to guided family-centred care was conducted by monitoring (1) knowledge, (2) delivery, (3) practice uptake and (4) certification.

RESULTS

Implementation was improved by the development of a strategic framework and by adjusting the framework according to the real-life context of a busy neonatal care unit. Promoting practice uptake was initially underestimated, but nurse guided family-centred care training was improved by increasing the visibility of the study in the unit, demonstrating intervention progress to the nurses and assuring a sense of ownership among nurse leaders and nonguided-family-centred-care-trained nurses.

CONCLUSIONS

An adjusted framework for guided family-centred care implementation was successful in overcoming barriers and promoting facilitators.

RELEVANCE TO CLINICAL PRACTICE

Insights gained from our pioneering work might help nurses in a similar context to reach their goals of improving family-centred care.

What do we really know about the treatment of delirium with antipsychotics? Ten key issues for delirium pharmacotherapy

Despite the significant burden of delirium among hospitalized adults, no pharmacologic intervention is approved for delirium treatment. Antipsychotic agents are the best studied but there are uncertainties as to how these agents can be optimally applied in everyday practice. We searched Medline and PubMed databases for publications from 1980 to April 2012 to identify studies of delirium treatment with antipsychotic agents. Studies of primary prevention using pharmacotherapy were not included. We identified 28 prospective studies that met our inclusion criteria, of which 15 were comparison studies (11 randomized), 2 of which were placebo-controlled. The quality of comparison studies was assessed using the Jadad scale. The DRS (N = 12) and DRS-R98 (N = 9) were the most commonly used instruments for measuring responsiveness. These studies suggest that around 75% of delirious patients who receive short-term treatment with low-dose antipsychotics experience clinical response. Response rates appear quite consistent across different patient groups and treatment settings. Studies do not suggest significant differences in efficacy for haloperidol versus atypical agents, but report higher rates of extrapyramidal side effects with haloperidol. Comorbid dementia may be associated with reduced response rates but this requires further study. The available evidence does not indicate major differences in response rates between clinical subtypes of delirium. The extent to which therapeutic effects can be explained by alleviation of specific symptoms (e.g. sleep or behavioral disturbances) versus a syndromal effect that encompasses both cognitive and noncognitive symptoms of delirium is not known. Future research needs to explore the relationship between therapeutic effects and changes in pathophysiological markers of delirium. Less than half of reports were rated as reasonable quality evidence on the Jadad scale, highlighting the need for future studies of better quality design, and in particular incorporating placebo-controlled work.

Top 10 myths regarding sedation and delirium in the ICU

The management of pain, agitation, and delirium in critically ill patients can be complicated by multiple factors. Decisions to administer opioids, sedatives, and antipsychotic medications are frequently driven by a desire to facilitate patients' comfort and their tolerance of invasive procedures or other interventions within the ICU. Despite accumulating evidence supporting new strategies to optimize pain, sedation, and delirium practices in the ICU, many critical care practitioners continue to embrace false perceptions regarding appropriate management in these critically ill patients. This article explores these perceptions in more detail and offers new evidence-based strategies to help critical care practitioners better manage sedation and delirium, particularly in ICU patients.

Implementing delirium screening in the ICU: secrets to success

OBJECTIVE

To review delirium screening tools available for use in the adult ICU and PICU, to review evidence-based delirium screening implementation, and to discuss common pitfalls encountered during delirium screening in the ICU.

DATA SOURCES

Review of delirium screening literature and expert opinion.

RESULTS

Over the past decade, tools specifically designed for use in critically ill adults and children have been developed and validated. Delirium screening has been effectively implemented across many ICU settings. Keys to effective implementation include addressing barriers to routine screening, multifaceted training such as lectures, case-based scenarios, one-on-one teaching, and real-time feedback of delirium screening, and interdisciplinary communication through discussion of a patient's delirium status during bedside rounds and through documentation systems. If delirium is present, clinicians should search for reversible or treatable causes because it is often multifactorial.

CONCLUSION

Implementation of effective delirium screening is feasible but requires attention to implementation methods, including a change in the current ICU culture that believes delirium is inevitable or a normal part of a critical illness, to a future culture that views delirium as a dangerous syndrome which portends poor clinical outcomes and which is potentially modifiable depending on the individual patients circumstances.

Educational interventions to improve recognition of delirium: a systematic review

Delirium is a common and serious condition that is underrecognized in older adults in a variety of healthcare settings. It is poorly recognized because of deficiencies in provider knowledge and its atypical presentation. Early recognition of delirium is warranted to better manage the disease and prevent the adverse outcomes associated with it. The purpose of this article is to review the literature concerning educational interventions focusing on recognition of delirium. The Medline and Cumulative Index to Nursing and Allied Health Literature (CINHAL) databases were searched for studies with specific educational focus in the recognition of delirium, and 26 studies with various designs were identified. The types of interventions used were classified according to the Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model, and outcomes were sorted according to Kirkpatrick's hierarchy. Educational strategies combining predisposing, enabling, and reinforcing factors achieved better results than strategies that included one or two of these components. Studies using predisposing, enabling, and reinforcing strategies together were more often effective in producing changes in staff behavior and participant outcomes. Based on this review, improvements in knowledge and skill alone seem insufficient to favorably influence recognition of delirium. Educational interventions to recognize delirium are most effective when formal teaching is interactive and is combined with strategies including engaging leadership and using clinical pathways and assessment tools. The goal of the current study was to systematically review the published literature to determine the effect of educational interventions on recognition of delirium.

Haloperidol prophylaxis in critically ill patients with a high risk for delirium

Introduction

Delirium is associated with increased morbidity and mortality. We implemented a delirium prevention policy in intensive care unit (ICU) patients with a high risk of developing delirium, and evaluated if our policy resulted in quality improvement of relevant delirium outcome measures.

Methods

This study was a before/after evaluation of a delirium prevention project using prophylactic treatment with haloperidol. Patients with a predicted risk for delirium of ≥ 50%, or with a history of alcohol abuse or dementia, were identified. According to the prevention protocol these patients received haloperidol 1 mg/8 h. Evaluation was primarily focused on delirium incidence, delirium free days without coma and 28-day mortality. Results of prophylactic treatment were compared with a historical control group and a contemporary group that did not receive haloperidol prophylaxis mainly due to non-compliance to the protocol mostly during the implementation phase.

Results

In 12 months, 177 patients received haloperidol prophylaxis. Except for sepsis, patient characteristics were comparable between the prevention and the historical (n = 299) groups. Predicted chance to develop delirium was 75 ± 19% and 73 ± 22%, respectively. Haloperidol prophylaxis resulted in a lower delirium incidence (65% vs. 75%, P = 0.01), and more delirium-free-days (median 20 days (IQR 8 to 27) vs. median 13 days (3 to 27), P = 0.003) in the intervention group compared to the control group. Cox-regression analysis adjusted for sepsis showed a hazard rate of 0.80 (95% confidence interval 0.66 to 0.98) for 28-day mortality. Beneficial effects of haloperidol appeared most pronounced in the patients with the highest risk for delirium. Furthermore, haloperidol prophylaxis resulted in less ICU re-admissions (11% vs. 18%, P = 0.03) and unplanned removal of tubes/lines (12% vs. 19%, P = 0.02). Haloperidol was stopped in 12 patients because of QTc-time prolongation (n = 9), renal failure (n = 1) or suspected neurological side-effects (n = 2). No other side-effects were reported. Patients who were not treated during the intervention period (n = 59) showed similar results compared to the untreated historical control group.

Conclusions

Our evaluation study suggests that prophylactic treatment with low dose haloperidol in critically ill patients with a high risk for delirium probably has beneficial effects. These results warrant confirmation in a randomized controlled trial.

Trial registration

clinicaltrial.gov Identifier: NCT01187667.

Delirium in critically ill patients: epidemiology, pathophysiology, diagnosis and management

Delirium is commonly observed in critically ill patients and is associated with negative outcomes. The pathophysiology of delirium is not completely understood. However, alterations to neurotransmitters, especially acetylcholine and dopamine, inflammatory pathways and an aberrant stress response are proposed mechanisms leading to intensive care unit (ICU) delirium. Detection of delirium using a validated delirium assessment tool makes early treatment possible, which may improve prognosis. Patients at high risk of delirium, especially those with cognitive decline and advanced age, should be identified in the first 24 hours of admission to the ICU. Whether these high-risk patients benefit from haloperidol prophylaxis deserves further study. The effectiveness of a multicomponent, non-pharmacological approach is shown in non-ICU patients, which provides proof of concept for use in the ICU. The few studies on this approach in ICU patients suggest that the burden of ICU delirium may be reduced by early mobility, increased daylight exposure and the use of earplugs. In addition, the combined use of sedation, ventilation, delirium and physical therapy protocols can reduce the frequency and severity of adverse outcomes and should become part of routine practice in the ICU, as should avoidance of deliriogenic medication such as anticholinergic drugs and benzodiazepines. Once delirium develops, symptomatic treatment with antipsychotics is recommended, with haloperidol being the drug of first choice. However, there is limited evidence on the safety and effectiveness of antipsychotics in ICU delirium.

A questionnaire survey of critical care nurses' attitudes to delirium assessment before and after introduction of the CAM-ICU

BACKGROUND

Nurses are usually the first to identify delirium in ICU patients. We aimed to assess the attitudes of Australian critical care nurses when we introduced the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU).

METHODS

We surveyed all 174 nurses in our ICU using two questionnaires: first after a one-month period of mandated but unstructured delirium assessments, and then following one month of CAM-ICU assessments. We also quantified antipsychotic medication usage by inspecting pharmacy records.

FINDINGS

The first survey response rate was 65/174 (37%). Most nurses (73%) thought active delirium assessment was important, and 93% thought their assessments were worth the time required. These assessments were largely unstructured, as only 20% knew a formal delirium test, and only 7% sometimes used one. The second survey response rate was 45/174 (26%). Most (89%) still thought delirium assessment was important, but only 75% thought the CAM-ICU worth the time required (p=0.01 compared to unstructured assessments). Similar proportions (75% and 73%) were confident in the accuracy of their assessments. Many (33%) found the CAM-ICU 'quite' or 'very' hard to perform, but despite this, 82% wanted to continue to use it. Free-text answers suggested this was because medical staff paid more attention to the CAM-ICU. Supporting this, prescriptions of antipsychotic medications increased significantly in the CAM-ICU period.

CONCLUSION

Critical care nurses in our Australian ICU who responded to our survey think delirium assessment is important. Although they find unstructured assessments easier to perform, they wanted to persist with the CAM-ICU, in part because it facilitated more appropriate pharmacological treatment of delirium for their patients. We recommend the CAM-ICU as a tool to improve communication between nurses and physicians in the management of delirium.

Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicentre study

OBJECTIVES

To develop and validate a delirium prediction model for adult intensive care patients and determine its additional value compared with prediction by caregivers.

DESIGN

Observational multicentre study.

SETTING

Five intensive care units in the Netherlands (two university hospitals and three university affiliated teaching hospitals).

PARTICIPANTS

3056 intensive care patients aged 18 years or over.

MAIN OUTCOME MEASURE

Development of delirium (defined as at least one positive delirium screening) during patients' stay in intensive care.

RESULTS

The model was developed using 1613 consecutive intensive care patients in one hospital and temporally validated using 549 patients from the same hospital. For external validation, data were collected from 894 patients in four other hospitals. The prediction (PRE-DELIRIC) model contains 10 risk factors-age, APACHE-II score, admission group, coma, infection, metabolic acidosis, use of sedatives and morphine, urea concentration, and urgent admission. The model had an area under the receiver operating characteristics curve of 0.87 (95% confidence interval 0.85 to 0.89) and 0.86 after bootstrapping. Temporal validation and external validation resulted in areas under the curve of 0.89 (0.86 to 0.92) and 0.84 (0.82 to 0.87). The pooled area under the receiver operating characteristics curve (n=3056) was 0.85 (0.84 to 0.87). The area under the curve for nurses' and physicians' predictions (n=124) was significantly lower at 0.59 (0.49 to 0.70) for both.

CONCLUSION

The PRE-DELIRIC model for intensive care patients consists of 10 risk factors that are readily available within 24 hours after intensive care admission and has a high predictive value. Clinical prediction by nurses and physicians performed significantly worse. The model allows for early prediction of delirium and initiation of preventive measures. Trial registration Clinical trials NCT00604773 (development study) and NCT00961389 (validation study).

Delirium: a review of the nurses role in the intensive care unit

AIM

This article aims to review current literature into the use of assessment tools for the diagnosis of delirium and the implications of care for the patient with delirium.

BACKGROUND

Delirium is a common often misdiagnosed, unrecognised and misunderstood condition in the critical care setting that has been associated with increased mortality and cognitive dysfunction.

RELEVANCE TO CLINICAL PRACTICE

Delirium has implications for increasing cost to the National Health Service as it is linked to prolonged ventilation and the associated risks and increased hospital stay.

CONCLUSION

Nurses play a key role in identification of delirium using CAM-ICU, a valid and reliable tool and identifying modifiable risks to improve the delirious ICU patient's outcome.